INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on January 14 through 16, 2008 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Aldie Foundation Inc. was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility. The following deficiencies were identified during this inspection and a plan of correction is due on February 25, 2008.
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Plan of Correction
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704.11(a)(1) LICENSURE Training Needs assessments
704.11. Staff development program.
(a) Components. The project director shall develop a comprehensive staff development program for agency personnel including policies and procedures for the program indicating who is responsible and the time frames for completion of the following components:
(1) An assessment of staff training needs.
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Observations
Based on a review of personnel and training records, the facility failed to document assessment of staff training needs for the 2007 - 2008 training year in six of six records reviewed, #1, 2, 3, 4, 5 and 6.
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Plan of Correction
In recent months there have been several staff changes which impacted the identification of a point person to manage staff training needs.
The site coordinator will develop and implement a timeline for identifying and insuring that all staff training needs are identified, assessed and documented. All current training files, included those noted during the inspection, will be brought into compliance by 4/1/08.
Site coordinators will ensure compliance through the development of a system of checks and balances across sites to monitor training benchmarks.
All Staff training needs for 2007-2008 will be re-assessed and all non-compliant training needs assessment charts will be brought up to date.
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704.11(c)(1) LICENSURE Mandatory Communicable Disease Training
704.11. Staff development program.
(c) General training requirements.
(1) Staff persons and volunteers shall receive a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum. Counselors and counselor assistants shall complete the training within the first year of employment. All other staff shall complete the training within the first 2 years of employment.
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Observations
Based on a review of training records, the facility failed to document HIV/AIDS or STD/TB in two of six records reviewed, #6 and 8. There was no documentation of 4 hours of STD/TB training in record #6. There was no documentation of 6 hours of HIV/AIDS and 4 hours of STD/TB training in record #8.
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Plan of Correction
In recent months there have been several staff changes which impacted the identification of a point person to manage staff training needs.
Therapist #6 and #8 will be attending the State Mandated-TB/STD Training @ The Behavioral Health Training and Education Office on March 27, 2008. Counselor #8 will be attending the mandatory HIV/AIDS on May 5, 2008.The coordinator will insure compliance through the collection and review of training documentation and certification. |
704.11(f)(2) LICENSURE Trng Hours Req-Coun
704.11. Staff development program.
(f) Training requirements for counselors.
(2) Each counselor shall complete at least 25 clock hours of training annually in areas such as:
(i) Client recordkeeping.
(ii) Confidentiality.
(iii) Pharmacology.
(iv) Treatment planning.
(v) Counseling techniques.
(vi) Drug and alcohol assessment.
(vii) Codependency.
(viii) Adult Children of Alcoholics (ACOA) issues.
(ix) Disease of addiction.
(x) Aftercare planning.
(xi) Principles of Alcoholics Anonymous and Narcotics Anonymous.
(xii) Ethics.
(xiii) Substance abuse trends.
(xiv) Interaction of addiction and mental illness.
(xv) Cultural awareness.
(xvi) Sexual harassment.
(xvii) Developmental psychology.
(xviii) Relapse prevention.
(3) If a counselor has been designated as lead counselor supervising other counselors, the training shall include courses appropriate to the functions of this position and a Department approved core curriculum or comparable training in supervision.
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Observations
Based on a review of training records, the facility failed to document 25 hours of training for the July 2006 to June 2007 training year in one of four record reviewed, #4. Employee #4 earned only 21.5 hours of training.
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Plan of Correction
In recent months there have been several staff changes which impacted the identification of a point person to manage staff training needs.
Training hours will now be monitored monthly by the Supervisor, who will email staff who are low on training hours. We believe this system will allow administrations to more effectively monitor the training hours of all staff and to assure that staff is completing trainings as required. An assessment of staff training needs will be distributed to all employees on an annual basis. The needs assessment form will be placed in the employees personnel file. Plan of correction will be put in place immediately. Site coordinators will insure compliance through the development of a system of checks and balances across sites to monitor training benchmarks.
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705.28 (c) (4) LICENSURE Fire safety.
705.28. Fire safety.
(c) Fire extinguishers. The nonresidential facility shall:
(4) Instruct staff in the use of the fire extinguisher upon staff employment. This instruction shall be documented by the facility.
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Observations
Based on a review of personnel and training records, the facility failed to document the fire extinguisher training in one of two records reviewed, #7.
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Plan of Correction
Deficiency occurred due to oversight of the regulation of requiring orientation to the use of fire extinguisher training. Documentation of training in regard to the use of fire extinguishers will be done at the time of hire when the new hire receives all orientation paperwork. The new employee will receive a certificate attesting to the completion fire of extinguisher training. This will begin immediately. Staff #7 will receive this training immediately. The coordinator will insure compliance through quarterly review of new hire personnel records and training files. |
705.28 (d) (3) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(3) Ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies.
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Observations
Based on a review of personnel and training records, the facility failed to document the training of staff to perform assigned tasks during emergencies in one of two records reviewed, #7.
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Plan of Correction
Deficiency occurred due to oversight of the regulation of requiring orientation in task assignment during emergency procedures is provided to all new staff within 7 days of hire. Documentation of training in regard to emergency procedures will be done at the time of hire when the new hire receives all orientation paperwork. The new employee will receive a certificate attesting to the completion of emergency procedure training. Staff #7 will receive this training immediately.The coordinator will ensure complinace through quarterly review of new hire personnel records and training files. |
709.82(e)(6) LICENSURE Treatment and rehabilitation services
709.82. Treatment and rehabilitation services.
(e) The project shall assist the client in obtaining the following supportive services when necessary:
(6) Vocational.
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Observations
Based on a review of administrative documentation, the facility failed to document assisting the clients in obtaining vocational support services. The letter of agreement with the Bucks County Office of Employment and Training had expired on July 25, 2007.
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Plan of Correction
All referral agreements were mailed out in a timely manner. At the time of licensing a response from The Bucks County Office of Employment and Training had not been received.
The office manager will obtain a current referral agreement with the Bucks County office of Employment and Training. The Program Coordinator will train all clinical staff on case management and resource development as a key element in the development of treatment plan goals. A spread sheet will also be developed to track the distribution and receipt of all referral agreements. All actions will be completed by 3/1/08.
The program coordinator will insure compliance with the utilization of comprehensive support services through the review and cosigning of client case consultations.
The office manager will be responsible for the maintenance of the referral agreement tracking sheet.
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709.23(b) LICENSURE Project Director
709.23. Project director.
(b) The project director shall assist the governing body in formulating policy and shall present the following to the governing body at least annually:
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Observations
Based on a review of administrative materials, the facility failed to document that the 2007-2008 project goals and objectives were presented to the Board.
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Plan of Correction
The project goals were scheduled to be presented at a board meeting where a quorum was not present for review. This item was rescheduled for a following board meeting and was subsequently overlooked.
The Project Director will present the 2007 ? 2008 project goals at the next board meeting. Compliance will be indicated by documentation in the minutes
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709.28(c)(3) LICENSURE Confidentiality
709.28. Confidentiality.
(c) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record. The consent shall be in writing and include, but not be limited to:
(3) Purpose of disclosure.
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Observations
Based on a review of the client records, the facility failed to obtain an informed in voluntary consent in four of nine client records reviewed, #1, 4, 5 and 9. Consents to release information to the clients' family members, the Department of Public Welfare/Magellan Behavioral Health and the clients' probation/parole officers did not have the purpose identified.
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Plan of Correction
Clinicians' do not consistently indicate the purpose of disclosure when completing an informed and voluntary consent.
Effective immediately, the Outpatient Coordinator will ensure that all current consents to disclose information forms will include the following: name of the person or agency to whom the disclosure will be made, specific information to be disclosed, the purpose of the disclosure, dated signature of client and witness and an expiration date of the consent. Secondly, the Outpatient Supervisor will conduct a training by 3/12/08 with all staff, addressing the appropriate procedures for obtaining informed consent, which shall include The Purpose of Disclosure and proper information to be disclosed specific to PA code 255.5. All consents will be checked at the intake QA session to insure compliance.
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709.91(b)(6) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
Based on a review of the client records, the facility failed to complete a psychosocial evaluation in six of nine client records reviewed, #1, 3, 4, 5, 6, 8 and 9. Psychosocial evaluations did not provide an assessment of the client's assets/strengths, coping mechanisms, and negative factors that may inhibit treatment. Additionally, the facility failed to complete the psychosocial evaluations within 30 days as per the project's policies in two of nine client record reviewed, #2 and 3.
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Plan of Correction
Clinicians do not consistently fully comprehend the need to synthesize the factual information gathered in the intake into a clinical evaluation of assets/strengths/ support systems and coping mechanisms, as well as the required timeframes for completion of this document.
Program coordinator will provide training by 3/12/08 regarding the completion of an evaluative, not merely historical, psychosocial assessment. Specific attention will be paid to the assessment of collected clinical data and the allowable timeframes for completion.
Program coordinator will insure compliance by reviewing the psychosocial assessments prior to co-signing clinicians' signature and all supervisors will ensure that all psychosocial evaluations are completed within 30 days. Additionally, training will be held on 3/12/08 to ensure that all clinicians understand and know the importance of assessing the client's strengths and coping mechanisms along with negative factors that may inhibit their treatment at Aldie.
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709.92(b) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 60 days.
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Observations
Based on a review of client records, the facility failed to document an assessment of the client's progress in relationship to the stated goals of the comprehensive treatment plan in four of nine client records reviewed, #4, 5, 6 and 9. Additionally, the facility failed to document a treatment plan update within 60 days of the comprehensive treatment plan in one of nine client records reviewed, #1.
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Plan of Correction
Clinicians do not consistently comprehend the need to assess clients progress in relationship to stated goals as well as the required time frames to do so.
Outpatient Coordinator will perform an In-service for staff on 3/12/08 on how to prepare a treatment plan relating the client's progress in relationship to stated goals. This will use a technique of documenting treatment plan goals with measurable criteria. The Outpatient Coordinator will insure compliance by reviewing all treatment plans prior to cosigning clinicians signature. Additionally, during weekly supervision, charts and treatment plans will be reviewed to ensure timely updated treatment plans every 60 days.
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